ASN Wikibase Occurrence # 189907
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| Date: | Tuesday 26 January 2016 |
| Time: | 19:50 UTC |
| Type: |  British Aerospace ATP-F (LFD) |
| Owner/operator: | Atlantic Airlines |
| Registration: | G-BUUR |
| MSN: | 2024 |
| Year of manufacture: | 1990 |
| Engine model: | Pratt & Whitney Canada PW126 |
| Fatalities: | Fatalities: 0 / Occupants: 2 |
| Aircraft damage: | None |
| Category: | Serious incident |
| Location: | Guernsey Airport, Channel Islands (GCI/EGJB) -
 United Kingdom
|
| Phase: | Approach |
| Nature: | Cargo |
| Departure airport: | Jersey-States Airport, Channel Islands (JER/EGJJ) |
| Guernsey Airport, Channel Islands (GCI/EGJB) | |
| Investigating agency: | AAIB |
| Confidence Rating: |  Accident investigation report completed and information captured |
European Air Transport flight QY2889, operated by Atlantic Airlines, was involved in a serious incident when the crew encountered control difficulties near Guernsey Airport, Channel Islands.
The BAe ATP cargo plane departed Jersey, Channel Islands, at 19:40 hrs for a night cargo flight to Guernsey. The co-pilot, who was PF, had completed the operator’s BAe ATP training course the previous month and this was his first commercial aircraft type.
The crew reported that the autopilot would not disengage during the approach for a night landing at Guernsey in a strong crosswind. A manually flown go-around was initiated from low altitude and the newly-qualified co-pilot, who was Pilot Flying (PF), reported the aircraft then exhibited a strong pitch-up tendency. The commander also sensed excessive pitch-up and pushed forward on his control column to assist. Thereafter the crew were alerted to activation of the Standby Control System (SCS) with the left and right elevators operating in split control.
During the go-around, the elevator control system problems distracted the crew so they did not follow the standard go-around procedure resulting in late retraction of the gear and flaps.
After levelling, the pilots realised the autopilot was not engaged and immediately re-engaged it. The appropriate drill for SCS engagement was then actioned and they diverted to Jersey.
On completion of the flight, the crew reported the problems encountered to the operator and their engineers began system checks. It was not understood by the crew or those working on the aircraft that the event was a reportable serious incident and consequently, the Cockpit Voice Recording (CVR) of the event was not preserved and certain autopilot components were removed from the aircraft prior to the AAIB being notified on the evening of 27 January 2016.
Recorded flight data indicated the autopilot disengaged during the approach to Guernsey and examination of the aircraft revealed no technical defects that would have caused the incident. As the CVR was unavailable, it was not possible to ascertain if an audio autopilot disengagement alert was generated. Some human factors were identified which may have contributed to the incident. The operator has made changes to its training policies and its guidance concerning post-incident or accident response.
Conclusion:
Extensive examination and functional testing of the aircraft systems and components identified no failures that were associated with the reported occurrence. The available data indicated the autopilot disengaged on command although the pilots believed otherwise. As the operator had not isolated the recorders following the incident, a cockpit voice recording of the event was not available. It was therefore not possible to ascertain if the autopilot disengagement alert sounded at the moment the FDR recorded autopilot disengagement during the approach.
During the resultant go-around, the co-pilot recalled having to overcome a strong pitch-up force after power was set, which he then struggled to overcome. The data indicated the aircraft was trimmed nose-up after power was set, so this may have been the cause of the pitch-up force and the co-pilot’s opposition to this force may have led to the elevator control split. It is also possible the pilots briefly made opposing inputs on the control column and this caused the elevator split and activation of the SCS.
However, it was not possible to exclude the possibility that there was an intermittent fault within the autopilot system that then caused the system to oppose the co-pilot’s inputs and lead to the control split. The recorded data shows two brief recordings of autopilot engagement during the event which the investigation could not explain.
Once the elevators had split the pilots completed the go-around but deviated from SOPs while struggling with a stressful and disorientating situation. They re-engaged the autopilot without discussing any potential threats from this action and they did not use CRM principles designed to help deal with problem solving and decision making. The operator has since reviewed and updated its training of crews as a result of the findings from this incident.
Accident investigation:
 |
|
Sources:
1. AAIB: https://www.gov.uk/aaib-reports/aaib-investigation-to-bae-atp-g-buur
2. CAA: https://siteapps.caa.co.uk/g-info/rk=BUUR
Images:
Media:
AAIB report on BAe ATP autopilot confusion 26 Jan 16 https://t.co/8iY2YhEtyt pic.twitter.com/iOM5G4Nk9T
— AAIB (@aaibgovuk) September 8, 2016
Revision history:
| Date/time | Contributor | Updates |
|---|---|---|
| 08-Sep-2016 12:54 | harro | Added |
| 08-Sep-2016 13:10 | harro | Updated [Time, Aircraft type, Narrative, Photo, ] |
| 07-Oct-2016 13:17 | Dr.John Smith | Updated [Source, Embed code, Narrative] |
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